80

Volume 46 Number 2 June 2013

Research Report

Treatment of non-vital primary molar using lesion sterilization

and tissue repair (LSTR 3Mix-MP)

Tania Saskianti, Udijanto Tedjosasongko and Irmawati

Department of Pediatric Dentistry
Faculty of Dental Medicine, Universitas Airlangga
Surabaya - Indonesia

abstract
Background: Root canal preparation and anatomic variations of deciduous teeth often cause the child patient uncooperative and
sometimes the treatment failure. The non-threatening treatment and non-invasive approaches is needed to obtain a good cooperation
from child patient. Purpose: The study was aimed to clinically evaluate the use of 3Mix-MP- a combination of antibacterial drugs, i.e.
metronidazole, minocycline and ciprofloxacin (3Mix), and macrogol and propylene glycol (MP) - as pulp medicament on a necroses
primary molar. Methods: Subject were the children patients of Pediatric Dental Clinic Universitas Airlangga Dental Hospital. Eight
primary molars with pulp necroses due to dental caries were selected as samples. The treatment was done based on the concept of
lesion sterilization and tissue repair (LSTR) therapy. A slice of 3 Mix-MP pastes was placed in the cavity and then sealed with glass-
ionomer cement. Subjects were asked for recall visit in 1, 3 and 6 months post treatment, for clinical and radiographic evaluation. The
antibacterial effect of 3 Mix-MP was compared with tempophore on mixed bacteria of pulp cavity which was isolated prior to therapy.
The antibacterial effect was determined by measuring the inhibition zone after 24 hours anaerobe incubation. Results: Seven out
of 8 subjects on recall visit showed no acute or chronic clinical symptoms, such as fistulae, abscess, purulent exudates, swelling or
feel any pain during mastication. Microbiological test result showed LSTR 3Mix-MP had antibacterial effect higher than tempophore
(p<0.001). Conclusion: The study revealed that 3Mix-MP treatment showed clinical and radiographic positive response on necrose
primary molar.

Key words: LSTR 3Mix-MP, pulp necroses, primary teeth

abstrak
Latar belakang: Preparasi saluran akar dan variasi anatomi gigi sulung seringkali menyebabkan pasien anak tidak kooperatif
dan kadang menyebabkan kegagalan perawatan. Perawatan yang tidak menakutkan dan non-invasif diperlukan untuk mendapatkan
kerjasama yang baik dari pasien anak. Tujuan: Penelitian ini bertujuan untuk evaluasi klinis penggunaan 3Mix - MP- kombinasi obat
antibakteri, yaitu metronidazole, minocycline dan ciprofloxacin (3Mix), dan makrogol dan propilen glikol (MP) – sebagai pengobatan
pulpa pada gigi molar sulung yang nekrose. Metode: Subjek adalah pasien anak dari Klinik Kedokteran Gigi Anak Rumah Sakit Gigi &
Mulut Universitas Airlangga. Delapan gigi molar sulung dengan nekrosis pulpa akibat karies gigi dipilih sebagai sampel. Pengobatan
dilakukan berdasarkan konsep lesion sterilization and tissue repair (LSTR). Selapis pasta 3 Mix - MP ditempatkan di kavitas gigi dan
kemudian ditumpat dengan semen glass-ionomer. Subjek diminta untuk kontrol untuk evaluasi klinis dan radiografi 1, 3 dan 6 bulan
pasca perawatan. Efek antibakteri 3 Mix - MP terhadap bakteri campuran rongga pulpa yang diisolasi sebelum terapi dibandingkan
dengan tempophore . Efek antibakteri ditentukan dengan mengukur zona hambat setelah 24 jam inkubasi anaerob. Hasil: Tujuh dari
8 subjek pada saat kontrol tidak menunjukkan gejala klinis akut atau kronis, seperti fistula, abses, eksudat purulen, bengkak atau
Saskianti, et al.,: Treatment of non-vital primary molar using lesion sterilization 81

merasa sakit selama pengunyahan. Hasil uji mikrobiologi menunjukkan LSTR 3Mix - MP memiliki efek antibakteri yang lebih tinggi
daripada tempophore (p<0,001). Simpulan: Hasil penelitian menunjukkan bahwa penggunaan 3Mix - MP memberikan respon positif
pada perawatan molar sulung yang nekrotik secara klinis dan radiografis.

Kata kunci: LSTR 3Mix-MP, nekrose pulpa, gigi sulung

Correspondence: Tania Saskianti, c/o: Departemen Kedokteran Gigi Anak, Fakultas Kedokteran Gigi Universitas Airlangga. Jl. Prof.
Dr. Moestopo No. 47 Surabaya 60132, Indonesia. E-mail: taniapedo@yahoo.com

introduction Thus, in order to anticipate those problems, nowadays

Approximately 75% of the teeth with deep caries
have been found from clinical observation to have pulp
exposure. Over 90% of the asymptomatic teeth with deep
carious lesions could be successfully treated without pulp
exposure using indirect pulp therapy techniques, so the
premature extraction can be prevented. 1 Primary teeth play
an integral role in the development of occlusion. Premature
loss of a primary tooth through infection has the potential
to destabilize the developing occlusion with space loss,
arch collapse, and premature, delayed or ectopic eruption
of the permanent successor teeth. Effective pulp therapy in
the primary dentition must not only stabilize the affected
primary tooth, but also create a favorable environment for
normal exfoliation of the primary tooth. It does not harm
the developing enamel or disturb normal eruption of its
permanent successor. The primary teeth preserved, are
consider to be the best space maintenance treatment until
natural exfoliation.2
However, before treatment plan of primary molar with
deep caries was made, it is important to consider some
factors, e.g. age of children, the general health, the period of
permanent dental eruption, the severity of dental caries, the
cooperation of children, and the cost of treatment.3 These
examples, in any combination, illustrate many treatment
considerations that could be important in an individual
patient with pulp necrose.1 The general treatment for
primary molar teeth with diagnose of necroses pulp actually
consists of some root canal treatment techniques. However,
complete elimination of bacteria is not always achieved in
clinical practice due to the anatomical complexities of root
canals and consequent limitations of access by instruments
and irrigators. 4 Furthermore, root canal treatment procedure
in children is more challenging and difficult than in adult due
to the following reasons: behavior management problems in
children, limited mouth opening, complexities of the root
canal system, and danger of injuring the permanent tooth
bud. The variation and eventual alterations in the number
and size of the primary root canals made it inaccessible even
to the smallest endodontic instruments.1 In general, the least
invasive intervention that is predictably associated with a
healthy, adaptive healing response in the affected primary
or permanent tooth, therefore, is needed to be done.2 All
inflammatory periapical lesions should be initially treated
with conservative nonsurgical procedures.5
the Cariology Research Unit of Niigata University School
of Dentistry in Japan has developed the concept of lesion
sterilization and tissue repair (LSTR) by using combination
of metronidazole, ciprofloxacin, and minocycline (3Mix),
and combination of carrier materials, macrogol and
propylene glycol (MP) for disinfecting the lesion in oral
mouth, including dentinal, pulp, and periapical lesion. The
recovery of the infected tissue then is expected to occur if
the lesion is disinfected.6-8
In addition, in vitro and in situ researches are done
extensively for analyzing the affectivity of mixing
medicines (3Mix) towards bacteria in oral mouth, including
endodontic lesion in permanent teeth. The research of
LSTR 3Mix-MP on permanent dental actually has been
done before by Hoshino,9 Kuswandari,10 and Khalil,11
nevertheless, other supporting researches are still needed in
different places in order to examine whether this treatment
is also effective for primary molar teeth considering
with the morphological difference between the crown of
primary molar teeth and that of permanent teeth with many
difficulties in maintaining root canal. The wider dentin
tubules of primary molar teeth and the thinner enamel
of primary molar teeth than those of the permanent teeth
can make the spreading of bacteria into root canal easier.
Furthermore, in child patients treatment sometimes is
difficult to be achieved since the flat anatomy of root
canal in the primary molar teeth, and since it also have
many branches that can make the conventional root canal
treatment difficult.
Due to the polymicrobial nature of the infected root
canal, combination of antibacterial drug is required. The
treatment with LSTR is considered to be useful to cure the
pulp necroses since it can exterminate bacteria in root canal.
Clinical procedures of LSTR therapy is also simple and does
not need long and continual visiting, thus it makes dentists
easier to treat pulp necroses of primary molar teeth.6 The
aim of study was to evaluate the success of LSTR 3Mix-MP
treatment subjectively, clinically, and radiographically in
primary molar teeth with diagnosis of pulp necroses in 1,
3, and 6 months after the treatment. The study could give
an alternative treatment of pulp necroses in primary molar
teeth that is easily, simple, effective, cheap acceptable for
children.
82 Dent. J. (Maj. Ked. Gigi), Volume 46 Number 2 June 2013: 80–84
material and methods
This study was a clinical research study with the pre
test-post test control group design. The locations of study
were Clinic of Pediatric Dentistry Universitas Airlangga
Dental Hospital and Ikhlas Kindergarten at Jalan Sekolahan
22, Surabaya. The targeted population in this research were
the students of Ikhlas Kindergarten (51 children) who meet
the criteria of sample. The samples were the maxillary or
mandibulary primary molar teeth with diagnosis of pulp
necroses due to dental caries, based on the clinical and
radiologic examination. The teeth must also met criteria
of the following root canal treatment indication: the tooth
should be restorable after the treatment, the root was in full
length or 1/3 of root length resorbed based on periapical
radiographic. Patients were cooperative, had no any
systemic abnormality or not under medical therapy relating
with their systemic condition, had no allergic history with
any chemical materials and antibiotics, must be permitted
by their parents who then signs informed consent. Finally,
the method of sample collecting in the study was random
sampling.
The criteria of treatment success were subjective,
clinical and radiographic evaluations.12 The treatment
was subjectively considered to be success if the early
symptoms or spontaneous pain in percussion decreased or
disappeared in period of observation (1, 3, and 6 months).
The treatment was clinically considered to be success if the
patients with or without early symptoms or spontaneous
pain in percussion and fistula, inflammation of intra oral,
and subjective complains at the first visit had decreased, or
had no pain at all during observation period. The treatment
was considered to be radiographically success if the area
of periapical radiolucency decreased and had no new
periapical radiolucency at the end of observation period
(6 months).
Clinical examination conducted on primary molar
teeth with pulp necroses. This clinical examination was
aimed to examine the presence of gingival inflammation;
abscess or fistula; abnormal dental mobility; pain after light
pressure on tooth; and any spontaneous pain.2 Moreover,
radiographic examination before and after the treatment
was also needed to obtain some following information;
the existence of external root resorbtion of treated primary
molar tooth, the existence of internal root resorbtion of
treated primary molar tooth, the existence of bifurcation
involvement, and the existence of periapical radiolucency.2
For children who met the criteria of subject, their parents
were explained about the aims, the expected results,
the advantages and disadvantages of LSTR 3Mix-MP
treatment, and the stages of the research as well as the
schedule of recall visit. After the parents approved it, they
signed the informed consent.
Tools and hand instruments were sterilized prior the
examination. Enteric coating and capsule covering the
medicine were opened. Each of the medicines then was
smoothened by using porcelain mortar and pestle. The
powder was stored in covered container, and saved in
refrigerator at the temperature of 16o C. Next, the powder
was mixed with the ratio of metronidazole 500 mg:
ciprofloxacin 500 mg: minocycline 500 mg (3Mix) = 1:3:3.
And, the carrier materials then were mixed with macrogol
and propylene glycol (MP) = 1:1. Finally, those mixing
medical powder were mixed with the carrier materials for
forming pasta 3 Mix-MP. The isolation of working area
must be conducted in children by using cotton roll. The
wall of dental cavity was cleaned chemically by using
35% of phosphate acid. The cavity then was half-filled
with 3Mix-MP and covered with glassionomer cement Fuji
IX with liquid consistency (the ratio 1 powder: 2 liquid)
without pressure. At recall visit (1, 3, and 6 months post-
treatment) aanamnesis was conducted towards the patients’
parents. In intra oral examination on treated teeth of the
children, moreover, palpation, percussion, and pressure
examinations were conducted. Then, radiology examination
was conducted. The obtained data, finally, were noted in
the prepared form.
Sterile paper point was put into the dental root canal
for 1 minute to obtain mixed bacteria in the necrose pulp.
Paper point then was put into the medium tube containing
BHI Broth, and aerobically incubated for 24 hours. The
blood agar was divided into 4 zones. Bacteria culture in
the BHI Broth was taken by micropipette. Each of zones of
blood agar was given one drop (10 µliter), and leveled with
spreader. Afterwards, LSTR 3Mix-MP and Tempophore,
about half of measuring spoon, were applied in each of
absorbed papers. Those absorbed papers then were put on
Blood Agar and anaerobically incubated in for 48 hours.
The antibacterial effect determined by the inhibition zone.
The bigger zone of inhibition the stronger its antibacterial
effect.
results
Based on the observation of LSTR 3Mix-MP treatment
on the 4-6 year old children of TK Ikhlas in Surabaya, 7
of 8 children were successfully treated with LSTR 3Mix-
MP. There were 5 children who were successfully treated
without any complains and 2 children were successfully
treated though they got pain in the first and third months,
but they recovered in the sixth month. There was one
child who was not successfully treated. Moreover, during
the examination of subjective symptom one month after
LSTR 3Mix-MP treatment, there were 3 students got pain.
One student reliefed the pain at the third month, yet the
pain emerged again at the sixth month. The two children
recovered their pain from the third month to the sixth month.
However, there was one student who had pain during
mastication at the sixth month. Meanwhile, five children
had no pain from the start and had stable condition until
the end of the treatment.
The radiographic examination result, however, was
difficult to measured since from the beginning of treatment
Saskianti, et al.,: Treatment of non-vital primary molar using lesion sterilization
there was no periapical radiolucency or resorbtion of
alveolar bone in seven of eight children. In general,
LSTR 3Mix-MP treatment radiographically did not show
differences between before and after the treatment.
Nevertheless, there was permanent radiolucency in one
child and physiologic resorbtion in one of the primary
molar root (data not shown). Based on the result, it showed
that average of the inhibition zone of LSTR 3Mix-MP was
bigger than that of Tempophore on bacteria culture of root
canal (Table 1).
Before taking the test for measuring the difference
of inhibition zone between LSTR 3Mix-MP group and
Tempophore group, statistic test had been taken on
each group for analyzing the distribution of the data.
Kolmogorov Smirnov test on LSTR 3Mix-MP group and
Tempophore groups were more than 0.05 which means
that either LSTR 3Mix-MP group or Tempophore group
has normal distribution of the data.
Moreover, in order to determined the difference of
resistance zone between LSTR 3Mix-MP and Tempophore
Independent t-test conducted. Based on the result of the
statistic test, it was known that p=0.001 (p<0.05). It means
that the difference of the inhibition zone was significant
between LSTR 3Mix-MP and Tempophore on bacteria
culture of root canal.
discussion
Based on the result it was known that the treatment
was successfully conducted in seven of eight children.
Similarly, the research conducted by Takushige 6 also
showed successfull LSTR 3Mix-MP treatment, about
79% of his cases. Besides that, the research conducted
by Kuswandari10 and Khalil11 also pointed out that LSTR
3Mix-MP treatment on primary molar teeth with diagnosis
of pulp necrose is considered to be a successful procedure,
which the level of success reached 100% in two months of
treatment. Furthermore, Kuswandari10 also stated that the
early condition of primary molar teeth before LSTR 3Mix-
MP treatment determined the level of clinical recovery.
It means that primary molar teeth without any clinical
symptoms in initial condition will recover faster that those
with periapical inflammation.
The failure in one child was due to broken restoration
of GIC at the first month and at the sixth month of the
treatment, so that the elimination of bacteria could not
be reached, and the child had pain during mastication.
According to Chugal et al.,14 eradication of microorganisms
from an infected root canal system is the key to successful
root canal treatment since there are millions of bacteria in
root canal with pulp necrose. Thus many bacteria infected
root canal, especially anaerob bacteria. The virulency
of endodontic flora is generally low, but the pathogenic
character and intraradicular defense are affected by the
combination of many factors, e.g. interaction with other
microorganisms in root canal, the ability of bacteria in
83
Table 1. The average of inhibition zone (mm)
Group n X SD
LSTR 3Mix-MP 10 38.0250 3.2789
Tempophore 10 19.9300 3.3067
Note: n = the number of research sample, SD = Standard
Deviation
disturbing the defense system of the host, the secretion of
lipopolysakarida (LPS) and other bacterial products, and
the enzyme synthesis breaking the tissue of the host. It is
also supported by Narayanan & Vaishnavi,15 that bacteria
can infect through many pathways, such as 1) through
dental crown or root after the broken pulp due to trauma; 2)
through periodontal tissue into broken dentin tubuli, lateral
cavity, and accessory cavity or apical and lateral foramen;
3) through lymphatic route or hematogenus (anakoresis).
Thus, in order to eliminate those bacteria more than one
antibiotic is needed.
LSTR 3Mix-MP is considered as the combination of
metronidazole, minocycline, and ciprofloxacin (3Mix),
and those three antibiotics mixed with macrogol and
propylene glycol (MP) were proven to be able to penetrate
efficiently through root canal and to disinfect the lesion of
caries. Laboratory test showed that LSTR 3 Mix-MP could
kill mixed bacteria in root canal more potent than that of
Tempohore. This result inline with the clinical result. Since
LSTR 3Mix-MP was bactericidal in aerob bacteria and in
obligate anaerob bacteria that are resistant, LSTR 3Mix-
MP could eliminate bacteria from dental tissue infected in
primary or permanent molar teeth. This assumption is that
by eliminating bacteria, the infection, inflammation, and
pain are also eliminated.6
The success of LSTR 3 Mix-MP treatment on those 5
samples was marked by the fact that it did not cause any
pain, or any clinical and radiological abnormality that
indicates the successful disinfection process of bacteria.
It is evident that in primary endodontic cases root canal
environment provides better nutritional supply, rich with
peptides and amino acids for bacterial inhabitants of
root canal system, so that elimination of microorganisms
from infected root canals is a difficult task.16 Due to the
polymicrobial nature of infected root canal, single empirical
antibiotic is insufficient in disinfection of the root canal.
Non specific antibiotic suppress most of the microbial flora
and allow residual virulent micro-organisms to repopulate
the root canal. Therefore it is essential to use combination
of antibiotics to act against all endodontic pathogens and
to prevent resistance.17
Besides the main root canal considering as capillary
blood vessel that can be cleaned, there are also many
additional root canal in primary molar teeth that cannot
be cleaned with mechanic tools.17 Thus, good material are
needed to deliver three-antibiotic mixture (3Mix) and create
asepsis condition either in the main or in the additional
root canal. Propylene glycol is solvent commonly used in
84 Dent. J. (Maj. Ked. Gigi), Volume 46 Number 2 June 2013: 80–84
industries, food, and daily goods. The penetration effect
of propylene glycol into root dentin was investigated by
Cruz et al.18 The area and the depth of penetration of
Safranin-O dye in propylene glycol were reported to be
significantly greater than dye with distilled water into root
dentine. Propylene glycol delivered dye through the root
canal system rapidly and more effectively indicating its
potential use in delivering intracanal medicaments. Lesion
sterilization and tissue repair (LSTR), involves the use of
antibacterials combined with a mixture of macrogol and
propylene glycol (MP) as the efficient vehicle to carry the
antibacterials within the tooth.
Like the procedure of indirect pulp capping, the
application of 3Mix-MP topically on dental lesion caries
in vivo could also be done by taking the tissue that cannot
be re-mineralized, and by leaving the tissue of caries in
the deepest area of cavity. Studies have shown that dentin
matrices contain reservoirs of bioactive molecules and
odontoblast capable of directing tissue repair. By sterilizing
the infection and not taking all dentin in pulp, it means that
dentin matrix is maintained and preserved as the reservoir
source of growth factor secreted by functional odontoblast
and pulp fibroblast.9,10,19 Growth factor then gives molecular
signal for the surviving post-mitotic odontoblast cells to
proliferate and differentiate to stimulates the secretion of
reactionary type of tertiary dentin matrix.21
LSTR treatment consisting of three-antibiotic mixture
could eliminate bacteria taken from carious lesions, pulp
necrose, infected root dentine and endodontic lesions of
permanent teeth20 and deciduous teeth6 that disturbing the
process of odontoblast proliferation and differentiation.
By using propylene glycol and macrogol considering as
carrier of materials (solvent), the growth factor in dentin
matrix was possibly penetrated into dentin tubuli, so it could
stimulate the form of tertiary dentin matrix. Based on this
advantage, the treatment of root canal with 3Mix-MP on
primary molar teeth with pulp infection could give positive
effect in this treatment.
Finally, LSTR 3Mix-MP treatment could be considered
to be successful if the tooth did not have any clinical
symptoms until that tooth was physiologically extracted
and then substituted by the permanent one. Therefore,
the evaluation was supposed to be done continually until
the tooth is physiologically extracted with the various
numbers of samples. The result of this research clinicaly and
radiographically showed that LSTR 3Mix-MP could be used
to treat primary molar teeth with pulp necrose diagnosis.
LSTR 3Mix-MP treatment can be used as an alternative
therapy for conventional root canal treatment in primary
molar teeth with pulp necrose diagnosis. Nevertheless, in
order to ensure the success rate and to examine other factors
determining the success of this treatment, it is needed to
take further research with the bigger number of samples in
the longer period, and by comparing with the conventional
treatment of root canal.
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